Schiappa Insurance Agency - Specialty Inflatables Form

FOR ANY QUESTIONS THAT DO NOT APPLY PLEASE TYPE N/A:

APPLICANT INFORMATION:

FIRST NAME:*

LAST NAME:*

COMPANY NAME INCLUDING DBA IF APPLICABLE:*

WEBSITE:*

BUSINESS ADDRESS:

STREET ADDRESS:*

CITY:*

ZIP CODE:*

STATE:*

ANY ADDITIONAL LOCATIONS:*

EMAIL ADDRESS:*

PHONE NUMBER:*

BEST TIME TO CALL:*

DATE BUSINESS STARTED UNDER CURRENT OWNERSHIP:*

IF LESS THAN 5 YEARS, PLEASE ANSWER THE FOLLOWING QUESTIONS:*

HAVE YOU WORKED ELSEWHERE IN A SIMILAR BUSINESS?*

HOW MANY YEARS?*

DO YOUR EMPLOYEES HAVE PRIOR EXPERIENCE?*

HOW MANY YEARS?*

FULL DECLARATION PAGE:

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LAST YEAR'S ANNUAL GROSS SALES:*

PROJECT CURRENT YEAR’S GROSS SALES:*

ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE LAST THREE YEARS?*

FEIN:*

SPECIFIED INFLATABLES AND AMUSEMENT DEVICES:

DO YOU OFFER THE FOLLOWING TO YOUR CUSTOMERS:

USE THE DROPDOWN FOR YES OR NO AND ENTER THE ANNUAL RECEIPTS FOR ALL THE QUESTIONS ANSWERED AS "YES":

INFLATABLE RIDES/BOUNCE HOUSES:*

ANNUAL RECEIPTS:

INFLATABLE SLIDES:*

ANNUAL RECEIPTS:

SLIP N9 SLIDES (WATER USE):*

ANNUAL RECEIPTS:

CLIMBING WALLS(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

MECHANICAL RIDES(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

COIN OPERATED RIDES:*

ANNUAL RECEIPTS:

EURO BUNGEE/POWER BUNGEE JUMPING(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

MINIATURE TRAINS(MUST HAVE AN OPERATOR):*

ANNUAL RECEIPTS:

MINIATURE TRAINS AGE OF OPERATOR:*

FOOD CONCESSION EQUIPMENT:*

ANNUAL RECEIPTS:

GO KART TRACKS - ELECTRIC(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

GO KART TRACKS - ADULT(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

GO KART TRACKS - KIDDIE(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

ARCADES/GAMES/CRAFTS:*

ANNUAL RECEIPTS:

BATTING CAGES:*

ANNUAL RECEIPTS:

LASER TAG:*

ANNUAL RECEIPTS:

MINIATURE GOLF:*

ANNUAL RECEIPTS:

MECHANICAL BULLS(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

PONY RIDES(MUST BE ATTENDED):*

ANNUAL RECEIPTS:

MISCELLANEOUS ATTRACTIONS (ALL OTHER):*

ANNUAL RECEIPTS:

LIST OF CURRENT INVENTORY AND VALUES:*

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Additional Information:

DO YOU HAVE A WRITTEN RENTAL AGREEMENT?

Attach Document

DOES IT CONTAIN A HOLD-HARMLESS CLAUSE?*

COPY OF THE RENTAL AGREEMENT.:*

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DO YOU INSTALL/SET UP ALL UNITS FOR THE CUSTOMER?*

DO YOU HAVE A RENTAL CHECKLIST THAT IS REVIEWED WITH THE RENTAL CUSTOMER?

Attach Document

PLEASE ATTACH A COPY:*

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DO YOUR AMUSEMENT DEVICES/RIDES HAVE SIGNS CLEARLY MARKING AGE, HEIGHT AND SIZE LIMITATIONS?*

DO YOU RENT ANY EQUIPMENT TO COMMERCIAL RISKS?*

ARE ALL OF YOUR RIDES INSPECTED ANNUALLY?*

ARE ALL RIDES MANUFACTURED, ASSEMBLED AND REGISTERED BY A U. S. BUSINESS ENTITY?*

IF FOREIGN MANUFACTURED, DO YOU HAVE EVIDENCE OF PRODUCTS LIABILITY INSURANCE COVERAGE FROM THE MANUFACTURER?*

DO YOU HAVE A MAINTENANCE CHECKLIST?*

DO YOU KEEP MAINTENANCE AND TEST LOGS AND PRE-OPERATION INSPECTION REPORTS ON ALL EQUIPMENT? *

DO YOU FOLLOW THE MANUFACTURER'S MAINTENANCE AND TEST SCHEDULE?*

DO YOU HAVE A TRAINING PROGRAM FOR EMPLOYEES?*

DO YOU PERFORM CRIMINAL BACKGROUND CHECKS ON EMPLOYEES?*

ARE YOUR EMPLOYEES TRAINED TO STRICTLY ENFORCE ALL RULES AND REGULATIONS EVEN IF IT MEANS STOPPING A RIDE EARLY OR REFUSING A RIDE TO A CUSTOMER?*

LOSS/CLAIM INFORMATION:

3 YEARS LOSS RUNS:

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DESCRIBE ANY LOSSES VALUED AT $25,000 OR MORE, INCLUDING DEFENSE COSTS IF APPLICABLE:*

The Applicant represents that the above statements are true and that no material facts have been suppressed or misstated.

e-signature:

Date:

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